Anything new and cool in the dental world?

[flightdoc09]

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ER doc here. I saw something recently about the Japanese researching a drug that can help regrow native teeth? I'm sure it's a long ways away from reaching prime time. I also read that in Japan they use hydroxyapatite instead of fluoride, and now I see hydroxyapatite toothpaste advertising everywhere on amazon and elsewhere.

But I was curious if there's any other new, cool, or interesting developments in the dental world. Either in treatment, prevention, or just interesting facts on how dental health affects rest of the body health.

Thanks.

 

[Schindlerelactobaciloma]

Robots in China are starting to perform surgeries independently, with only human monitoring and no intervention at all.

 

[Torshammer]

Vibes

 

[New_Vegas]

It turns out hydroxyapatite toothpaste isn't that effective. It mostly serves as a toothpaste to cater to the crowd who subscribe to quackery. It's big among those crunchy mom groups to think fluoride is like the most toxic material on earth. When, in reality, they are missing the whole entire point of how it all works. Fluoride is effective because it makes the enamel less soluble in relation to acid attack. Dental caries are primarily the result of acid attack, because lactic acid is a byproduct of the metabolism of the cariogenic bacteria. And of course when used as directed, fluoride toothpaste is definitely safe. You just don't want to ingest excessive amounts of it.

 

[TanMan]

Not necessarily the newest, but the newest in speed sintering crowns with Katana One Speed. 9.5 minutes of sintering for zirconia is a game changer for workflows and cranking out crowns faster. Combined with Superfast milling at 3-6 minutes, you can crank out same day crowns at an even faster pace with no compromise in strength. If you have multiple mills, you can run patients in parallel and probably do 6+ crown patients an hour (if you didn't have things to get in your way like hygiene). It is a force multiplier that makes one dentist work like 3+ dentists.

 

[JacquesVallee]

Not necessarily the newest, but the newest in speed sintering crowns with Katana One Speed. 9.5 minutes of sintering for zirconia is a game changer for workflows and cranking out crowns faster. Combined with Superfast milling at 3-6 minutes, you can crank out same day crowns at an even faster pace with no compromise in strength. If you have multiple mills, you can run patients in parallel and probably do 6+ crown patients an hour (if you didn't have things to get in your way like hygiene). It is a force multiplier that makes one dentist work like 3+ dentists.

No issues with debonding or longevity overall? How long have you been using it?

 

[TanMan]

No issues with debonding or longevity overall? How long have you been using it?

Same day zirconia? At least 3-4 years, Katana Speed? Over a year, maybe 2 years. I'd estimate that we've done at least 1800 (based on our crown mix and total number of same day crowns over a 2 year period) crowns with Katana Speed.

Longevity is great, rarely any fractures (<1%), debonding is rare as well. Our protocol is sandblast w/ 50micron aluminum oxide at high psi (50-60psi), katana cleaner, zirconia primer. RelyX Unicem 2 self adhesive cement, cure for half a second, remove excess cement and interproximal cement within 12seconds, cure for another 3 seconds, check occlusion/excursives, adjust as needed, final radiograph, dismiss. By the time the final product gets to me, my assistants have done all the extraoral adjustments that need to be done to ensure good contacts, excursives, occlusion, etc... so I spend probably 2-3 minutes in the cementation phase. Staff has already gone over post-op instructions

 

[New_Vegas]

Same day zirconia? At least 3-4 years, Katana Speed? Over a year, maybe 2 years. I'd estimate that we've done at least 1800 (based on our crown mix and total number of same day crowns over a 2 year period) crowns with Katana Speed.

Longevity is great, rarely any fractures (<1%), debonding is rare as well. Our protocol is sandblast w/ 50micron aluminum oxide at high psi (50-60psi), katana cleaner, zirconia primer. RelyX Unicem 2 self adhesive cement, cure for half a second, remove excess cement and interproximal cement within 12seconds, cure for another 3 seconds, check occlusion/excursives, adjust as needed, final radiograph, dismiss. By the time the final product gets to me, my assistants have done all the extraoral adjustments that need to be done to ensure good contacts, excursives, occlusion, etc... so I spend probably 2-3 minutes in the cementation phase. Staff has already gone over post-op instructions

You run a well oiled machine, love it.

 

[TanMan]

You run a well oiled machine, love it.

It's all about keeping it simple, efficient, and predictable.

Another trend is 3D printing. 3D printing seems to be all the craze (the new and cool) these days, but what's not mentioned very often is the post-processing of dental appliances and crowns is technique sensitive and takes more time than the actual print itself. Ever had a 3d printed nightguard? We tried to implement it in our office and to reprint them several times for the heaviest bruxers within a span of months. We stopped when we found it was just easier to send it to the lab. The plus side of 3d printing is lower barrier to entry.

For 3d printing restorations, the crown material is weak and feels cheap. Doesn't matter if the material technically has >50% ceramic material to be billed as a ceramic crown/onlay/inlay, the ceramic filler is still in a sea of resin. Reminds of the nanoceramic hybrid blocks that are already available, but have a poor track record of staying bonded for full coverage restorations such as the lava ultimate or gc cerasmart.

We use our 3d printers primarily to fabricate models and extraorally adjust long span bridges. Our lab tends to prefer model-less fabrication of restorations, and sometimes, for more complex cases, it can help cut down chairtime to adjust extraorally.

ER doc here. I saw something recently about the Japanese researching a drug that can help regrow native teeth? I'm sure it's a long ways away from reaching prime time. I also read that in Japan they use hydroxyapatite instead of fluoride, and now I see hydroxyapatite toothpaste advertising everywhere on amazon and elsewhere.

But I was curious if there's any other new, cool, or interesting developments in the dental world. Either in treatment, prevention, or just interesting facts on how dental health affects rest of the body health.

Thanks.

Dental health is a reflection of a patient's overall mental and physical health. If people aren't taking care of their teeth, they sure as hell aren't taking care of the rest of their body. Also, more often than not, if a patient has multiple periodontal abscesses, it usually indicates uncontrolled diabetes. People who evidence of brux usually have major stress in their lives, use stimulants, antidepressants, cocaine/meth, sleep apnea, and/or have psychological disorders. Wear of the teeth (whether clenching or grinding) can give me a clue as to whether a patient is potentially going to be difficult.

Just some random things I picked up on with the 10s of thousands of patient's I've seen throughout my career.

 

[schmoob]

Not necessarily the newest, but the newest in speed sintering crowns with Katana One Speed. 9.5 minutes of sintering for zirconia is a game changer for workflows and cranking out crowns faster. Combined with Superfast milling at 3-6 minutes, you can crank out same day crowns at an even faster pace with no compromise in strength. If you have multiple mills, you can run patients in parallel and probably do 6+ crown patients an hour (if you didn't have things to get in your way like hygiene). It is a force multiplier that makes one dentist work like 3+ dentists.

Are you milling bridges or just single units? Also are you using zirconia strictly in the posterior, or are you using zirconia instead of e.max in the anterior?

 

[TanMan]

Are you milling bridges or just single units? Also are you using zirconia strictly in the posterior, or are you using zirconia instead of e.max in the anterior?

We do bridges and single units. 3 unit bridges and single units can be done in the same day. 4+ units can be done next day due to the 9.5 hour sintering time. Immediate bridges are popular if an extraction has to be done since patients walk out with a permanent restoration. We use zirconia in the anterior and posterior, but anteriors are on a case-by-case basis. Zirconia can match PFM's very well in the anterior. If the patient has multiple shade zones within the same tooth, I'd rather just send it out to the lab than mess around with staining systems such as miyo.

If the patient has a very dark stump, I don't like using emax. Even LT versions of emax with opaque cements aren't enough to cover dark stumps

 

[flightdoc09]

It turns out hydroxyapatite toothpaste isn't that effective. It mostly serves as a toothpaste to cater to the crowd who subscribe to quackery. It's big among those crunchy mom groups to think fluoride is like the most toxic material on earth. When, in reality, they are missing the whole entire point of how it all works. Fluoride is effective because it makes the enamel less soluble in relation to acid attack. Dental caries are primarily the result of acid attack, because lactic acid is a byproduct of the metabolism of the cariogenic bacteria. And of course when used as directed, fluoride toothpaste is definitely safe. You just don't want to ingest excessive amounts of it.

Another toothpaste I saw recently show up in an ad is something that looks like it is some sort calcium chelator. I think it's a derivative of EDTA. The idea is to be able to dissolve and lift off tartar. But I don't think it has fluoride or anything in it. Probably trying to market to the anti-fluoride crowd as well.


Also, another question that another post brought to mind, but how much mercury is still in use in fillings? I've heard it has largely gone away, but still in use somewhat. I another doc I was working with had a patient that came in once demanding treatment for mercury poisoning. He apparently had just gotten some dental work done and I think he bit into a filling, or temporary filling, or something. And he said a puff of smoke came out of his mouth and he felt off after that. He got very loud and angry when he was told no, and security had to be called.

 

[TanMan]

Another toothpaste I saw recently show up in an ad is something that looks like it is some sort calcium chelator. I think it's a derivative of EDTA. The idea is to be able to dissolve and lift off tartar. But I don't think it has fluoride or anything in it. Probably trying to market to the anti-fluoride crowd as well.


Also, another question that another post brought to mind, but how much mercury is still in use in fillings? I've heard it has largely gone away, but still in use somewhat. I another doc I was working with had a patient that came in once demanding treatment for mercury poisoning. He apparently had just gotten some dental work done and I think he bit into a filling, or temporary filling, or something. And he said a puff of smoke came out of his mouth and he felt off after that. He got very loud and angry when he was told no, and security had to be called.

Calcium chelator sounds like a horrible idea, especially if combined with anything acidic. That's what makes citric acid worse than HCl in terms of enamel decalcification.

Mercury is used in amalgam fillings. Most of it is released at the time of placement, the rest is trapped in an amalgamation of other metals (varies depending on the type of amalgam you use) until you remove the restoration. Whenever a patient suspects mercury poisoning, I recommend getting a blood test with their PCP to determine if they have any heavy metal toxicity before proceeding with removal. Removing amalgam, especially superwide ones w/ or w/o cusp capping and replacing with composite isn't always the best thing to do from a structural perspective (in b4 holistic/biomimetic dentistry). Also, there's always the risk of increased sensitivity from replacing restorations that were asymptomatic in the first place.

Amalgam fillings/restorations still have their place, but tbh, I haven't placed one since dental school. Placing a mouthful of amalgams in a patient isn't going to kill them, but I believe that chronic exposure to them as a dentist may affect my health over the lifespan of my career. Being exposed to it once isn't going to harm me, but over 10's of thousands of amalgam fillings, I'd consider it a potential occupational hazard. It's weird that when we place it in the mouth, it is ok, but when it comes to having amalgam separators, wastewater management, and protocols for disposal, all of a sudden it is considered toxic. Kind of like when a patient steps into your office, all of a sudden their own saliva becomes toxic since they need the saliva ejector constantly, haha.

 

[flightdoc09]

Another question. The fluoride in drinking water, is that supposed to work by just bathing the teeth as you drink? Or is there supposed to be some sort of benefit via systemic absorption and diffusion through the blood supply to the tooth? Because I know teeth have a blood supply and little channels in them. But I don't know if that blood supply and channels can effectively deliver anything to the surface of the teeth/enamel.

 

[New_Vegas]

Another question. The fluoride in drinking water, is that supposed to work by just bathing the teeth as you drink? Or is there supposed to be some sort of benefit via systemic absorption and diffusion through the blood supply to the tooth? Because I know teeth have a blood supply and little channels in them. But I don't know if that blood supply and channels can effectively deliver anything to the surface of the teeth/enamel.

Good question. There is no systemic benefit for the teeth by ingesting fluoride. It's only a topical benefit. So yes, the fluoride in drinking water only benefits as it is contact with the teeth. So if you brush with fluoride toothpaste you don't need it in your water lol. I use an RO system at my house for all drinking water so all that gets stripped out.

But the levels of fluoride in drinking water are low enough that overconsumption it's not a concern. In fact, the natural water supply in some areas has excessively high levels of fluoride in it, so at the water treatment facilities they actually remove fluoride from the water, as opposed to adding it.

 

[TanMan]

Another question. The fluoride in drinking water, is that supposed to work by just bathing the teeth as you drink? Or is there supposed to be some sort of benefit via systemic absorption and diffusion through the blood supply to the tooth? Because I know teeth have a blood supply and little channels in them. But I don't know if that blood supply and channels can effectively deliver anything to the surface of the teeth/enamel.

Much of the calcification of the tooth occurs before it even erupts out of the gingiva. I'd be more concerned about skeletal fluorosis and absorption/incorporation into bones/hard tissue than into teeth. Also, at high enough concentrations, fluoride can affect organ systems as well, but that would have to be a megadose of fluoride. I can't tell you outright the pharmacokinetics of fluoride, but a pharmacist might be able to.

As always, risk v. benefits. I think systemic fluoride has more risks than benefits, but as long as we keep it topical and not ingested, the benefits far outweigh the risks.

 

[JacquesVallee]

@TanMan How much longer do you think you'll practice? I vaguely remember years ago you mentioning retiring early.

 

[TanMan]

@TanMan How much longer do you think you'll practice? I vaguely remember years ago you mentioning retiring early.

As long as the money is good, remains interesting, and doesn't give me any headaches. Keeps me young at least, but I am reducing my hours and days more.

 

[TanMan]

But yeah, as you get older, 6 hours is already a lot. I don't know how people do 8 or even 10+ hours.

 

[New_Vegas]

But yeah, as you get older, 6 hours is already a lot. I don't know how people do 8 or even 10+ hours.

I've been doing 10 hour days. It's a slog.

 

[TanMan]

I've been doing 10 hour days. It's a slog.

Being stuck somewhere for 10 hours has got to be mentally exhausting in the very least.

 

[mjzccle19701]

Another question. The fluoride in drinking water, is that supposed to work by just bathing the teeth as you drink? Or is there supposed to be some sort of benefit via systemic absorption and diffusion through the blood supply to the tooth? Because I know teeth have a blood supply and little channels in them. But I don't know if that blood supply and channels can effectively deliver anything to the surface of the teeth/enamel.

Just to put it in perspective… a 70 kilogram person would need to drink 500 liters of water in one sitting to get a toxic dose of systemic fluoride. Systemic fluoride is important for developing teeth. A baby would need to drink like 40 liters to get a toxic dose.

 

[New_Vegas]

Just to put it in perspective… a 70 kilogram person would need to drink 500 liters of water in one sitting to get a toxic dose of systemic fluoride. Systemic fluoride is important for developing teeth. A baby would need to drink like 40 liters to get a toxic dose.

Nope, there's no systemic benefit to ingesting fluoride. That's an old myth that has been ruled out with modern research.

 

[mjzccle19701]

Nope, there's no systemic benefit to ingesting fluoride. That's an old myth that has been ruled out with modern research.

I don’t think I ever said there was a systemic benefit to ingesting fluoride. I specifically said it was beneficial to developing teeth. Not the rest of the body. There’s plenty of research showing systemic fluoride is beneficial to developing teeth. Topical fluoride has a more powerful effect but it doesn’t negate the former statement.

 

[schmoob]

Not sure how new but definitely cool.
I attended a lecture last year and it was a program director talking about tooth replacement.
They would take a CBCT of the third molar and 3D print it. They would extract the hopeless 1st molar and replace it with allograft and the printed tooth. They would let it heal for a few months and then remove the model. Then atraumatic extraction of the third molar with immediate autotransplantation into the 1st molar site with care not to damage the PDL fibers on the cementum. Bingo bango bongo, you’ve got yourself a new 1st molar.
This lecture was done by a program director for a well respected academic program at a University, not some quack who just thought of this idea and decided to offer a weekend CE course on it.
Anyway I thought that was pretty cool.

 

[TanMan]

Not sure how new but definitely cool.
I attended a lecture last year and it was a program director talking about tooth replacement.
They would take a CBCT of the third molar and 3D print it. They would extract the hopeless 1st molar and replace it with allograft and the printed tooth. They would let it heal for a few months and then remove the model. Then atraumatic extraction of the third molar with immediate autotransplantation into the 1st molar site with care not to damage the PDL fibers on the cementum. Bingo bango bongo, you’ve got yourself a new 1st molar.
This lecture was done by a program director for a well respected academic program at a University, not some quack who just thought of this idea and decided to offer a weekend CE course on it.
Anyway I thought that was pretty cool.

It sounds like autotransplantation with extra steps. Do they still have to do an extraoral rct like traditional autotransplantation? Also, what's the short term and long term success rates if the data is available and what are the potential advantages over titanium?

I wonder how the bone would react to the printed tooth. Ensuring full curing of every layer of the 3d printed tooth is going to be very important, especially if they are using some type of monomer as a lot of them are very cytotoxic. Unless they are printing with something else, but it has to be biocompatible.

 

[schmoob]

It sounds like autotransplantation with extra steps. Do they still have to do an extraoral rct like traditional autotransplantation? Also, what's the short term and long term success rates if the data is available and what are the potential advantages over titanium?

I wonder how the bone would react to the printed tooth. Ensuring full curing of every layer of the 3d printed tooth is going to be very important, especially if they are using some type of monomer as a lot of them are very cytotoxic. Unless they are printing with something else, but it has to be biocompatible.

He discussed extraoral RCT during the lecture however I don’t remember exactly if it was part of this autotransplantation procedure. It is possible that the 3D model was for GBR and a perfect fit for the 3rd molar which would make it easier to maintain pulpal vitality through neurovascular regeneration.
But you may be correct, ext 3rd molar, extraoral RCT, placement of tooth, fixation/splint until tooth has its own stability.
Not sure what resin is used but I would guess it would be something biocompatible to reduce the chance of cytotoxicity.
As far as success his presentation showed pretty good 5 and 10 year success rates but we all know that we need to read those statistics with a grain of salt.
As far as benefits over titanium, titanium will always be there. This is just an attempt to preserve natural tooth structure as much as possible. If autotransplantation fails, the patient can still get an implant.

 

[TanMan]

He discussed extraoral RCT during the lecture however I don’t remember exactly if it was part of this autotransplantation procedure. It is possible that the 3D model was for GBR and a perfect fit for the 3rd molar which would make it easier to maintain pulpal vitality through neurovascular regeneration.
But you may be correct, ext 3rd molar, extraoral RCT, placement of tooth, fixation/splint until tooth has its own stability.
Not sure what resin is used but I would guess it would be something biocompatible to reduce the chance of cytotoxicity.
As far as success his presentation showed pretty good 5 and 10 year success rates but we all know that we need to read those statistics with a grain of salt.
As far as benefits over titanium, titanium will always be there. This is just an attempt to preserve natural tooth structure as much as possible. If autotransplantation fails, the patient can still get an implant.

I am curious to see the histology or get an idea of how it looks like at the interface of the 3d printed model and bone/gingiva/whatever type of tissue forms around it. I wonder if they have to aggressively curette the socket after removing the 3d printed model prior to insertion of atraumatically extracted tooth.

Seems like a lot of work for something that could've been solved by a bridge or implant, especially if they going to try and remove a mesioangular/distoangular 3rd molar for reimplantation. I'm also assuming they are aiming for conical shaped roots and upright 3rd molars.

Anyway, I just thought of this for some reason:

 

[flightdoc09]

Calcium chelator sounds like a horrible idea, especially if combined with anything acidic. That's what makes citric acid worse than HCl in terms of enamel decalcification.

edathamil is the ingredient. Just saw another ad for Livfresh toothepaste that has it in it. Not sure if you've heard of it, but per google it's a form of EDTA. Just wanted to close the loop on this.

 

[TanMan]

edathamil is the ingredient. Just saw another ad for Livfresh toothepaste that has it in it. Not sure if you've heard of it, but per google it's a form of EDTA. Just wanted to close the loop on this.

It is time and concentration dependent on how it affects enamel and dentin. EDTA in low concentrations, usually in toothpastes, are insufficient to harm the enamel irreversibly. It can be used to remove the smear layer in root canal systems, but in high enough concentrations and longer periods of time, you will have erosion of the dentinal tubules.

If interested, look up SEMs on time dependent exposure of dentinal tubules to EDTA.